2017 Summary of

BENEFITS AARP® MedicareRx Walgreens (PDP) S0522-058 Our service area includes: Ohio.

This is a summary of drug coverages provided by AARP® MedicareRx Walgreens (PDP) January 1st, 2017 - December 31st, 2017. For more information, please contact Customer Service at:

Toll-Free 1-800-753-8004, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week

www.AARPMedicarePlans.com

Y0066_SB_S0522_058_2017 CMS Accepted

Summary of Benefits January 1st, 2017 - December 31st, 2017 We’re dedicated to providing clear and simple information about your plan so you always stay fully informed. The following information is a breakdown of what we cover and what you pay. This is called “cost-sharing” or “out-of-pocket” costs. Cost-sharing includes co-pays, co-insurance and deductibles. This will help you control your drug costs throughout the plan year. Keep in mind that this isn’t a full list of benefits we provide, it’s just an overview. To get a complete list, visit our website at www.AARPMedicarePlans.com to see the “Evidence of Coverage” or call customer service with any questions.

About this plan. AARP® MedicareRx Walgreens (PDP) is a Medicare Prescription Drug Plan approved by Medicare. To join AARP® MedicareRx Walgreens (PDP), you must be entitled to Medicare Part A, and/or be enrolled in Medicare Part B, live in our service area as listed on the cover.

What’s inside? Plan Premiums, Annual Deductibles, and Benefits See plan costs including the monthly plan premium and plan deductible. AARP® MedicareRx Walgreens (PDP) has a network of pharmacies. If you use out-of-network pharmacies, the plan may not pay for these drugs or you may pay more than you pay at an in-network pharmacy. You can search for a network pharmacy in the online directory at www.AARPMedicarePlans.com. Drug Coverage Look to see what drugs are covered along with any restrictions in our plan formulary (list of Part D prescription drugs) found at www.AARPMedicarePlans.com.

AARP® MedicareRx Walgreens (PDP) Premiums and Benefits Monthly Plan Premium

$22.40

Annual Prescription Drug Deductible

$0 per year for Tier 1 and Tier 2; $400 for Tier 3, Tier 4 and Tier 5 Part D prescription drugs.

Prescription Drugs If you reside in a long-term care facility, you pay the same for a 31-day supply as a 30-day supply at a Standard retail pharmacy. Stage 1: Annual Prescription Deductible

$0 per year for Tier 1 and Tier 2; $400 for Tier 3, Tier 4 and Tier 5.

Stage 2: Initial Coverage (After you pay your deductible, if applicable)

Retail

30-day supply

90-day supply

30-day supply

Tier 1: Preferred Generic Drugs

$0 co-pay

$0 co-pay

Tier 2: Generic Drugs

$3 co-pay

Tier 3: Preferred Brand Drugs

Mail Order

Preferred

Standard

Preferred

Standard

90-day supply

90-day supply

90-day supply

$15 co-pay

$45 co-pay

$0 co-pay

$45 co-pay

$9 co-pay

$18 co-pay

$54 co-pay

$9 co-pay

$54 co-pay

$27 co-pay

$81 co-pay

$47 co-pay

$141 co-pay

$81 co-pay

$141 co-pay

Tier 4: Non-Preferred Drugs

32% of the cost

32% of the cost

33% of the cost

33% of the cost

32% of the cost

33% of the cost

Tier 5: Specialty Tier Drugs

25% of the cost

25% of the cost

25% of the cost

25% of the cost

25% of the cost

25% of the cost

Stage 3: Coverage Gap Stage

After your total drug costs reach $3,700, you will pay no more than 51% of the total cost for generic drugs or 40% of the total cost for brand name drugs, for any drug tier during the coverage gap.

Stage 4: Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,950, you pay the greater of: • 5% of the cost, or • $3.30 co-pay for generic (including brand drugs treated as generic) and a $8.25 co-pay for all other drugs.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. The Formulary and/or pharmacy network may change at any time. You will receive notice when necessary. Premium and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. You are not required to use OptumRx home delivery for a 90 day supply of your maintenance medication. If you have not used OptumRx home delivery, you must approve the first prescription order sent directly from your doctor to OptumRx before it can be filled. New prescriptions from OptumRx should arrive within ten business days from the date the completed order is received, and refill orders should arrive in about seven business days. Contact OptumRx anytime at 1-877889-5802, TTY 711. OptumRx is an affiliate of UnitedHealthcare Insurance Company. AARP MedicareRx Walgreens (PDP)’s pharmacy network offers limited access to pharmacies with preferred cost sharing in urban ND and WV; suburban CA, HI, MD, ME, ND, NY, PA, WV and rural AK, AR, HI, IA, ID, KS, KY, ME, MN, MO, MS, MT, NE, NY, OK, PA, SD, TX, UT, VA, WA, WV and WY. There are an extremely limited number of preferred cost share pharmacies in urban VT and rural ND. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including pharmacies with preferred cost sharing, please call us or consult the online pharmacy directory using the contact information that appears on the booklet cover. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare. UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers. You do not need to be an AARP member to enroll. AARP encourages you to consider your needs when selecting products and does not make specific product or pharmacy recommendations for individuals. United contracts directly with Walgreens for this plan; AARP and its affiliates are not parties to that contractual relationship. NOTE: If you are receiving extra help from Medicare, your co-pays may be lower or you may have no co-pays. If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. This document is available in other formats such as Braille and large print. This document may be available in a non-English language. For additional information, call us at 1-800-753-8004.

This information is available for free in other languages. Please call our customer service number at 1-800-753-8004, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. Esta información está disponible sin costo en otros idiomas. Comuníquese con nuestro Servicio al Cliente al número 1-800-753-8004, TTY 711, 8 a.m. a 8 p.m. hora local, los 7 días de la semana.

Multi-language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-753-8004. Someone who speaks English/ Language can help you. This is a free service Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-800-753-8004. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 㒠ⅻ㙟∪⏜忈䤓劊幠㦜┰᧨ソ┸㌷屲䷣␂ℝ⋴ㅆ㒥嗾䓸≬棸䤓↊⇤䠠桽ᇭⰑ㨫㌷ 榏尐㷳劊幠㦜┰᧨庆咃䟄 1-800-753-8004ᇭ㒠ⅻ䤓₼㠖ぴ⇫ⅉ⛧㈗⃟㎞ソ┸㌷ᇭ扨㢾₏欈⏜忈㦜 ┰ᇭ Chinese Cantonese: ㌷⺜㒠⊠䤓⋴ㅆ㒥塴䓸≬椹♾厌ⷧ㦘䠠⟞᧨䍉㷳㒠⊠㙟∪⏜彊䤓劊巾㦜╨ᇭⰑ 榏劊巾㦜╨᧨嵚咃榊1-800-753-8004ᇭ㒠⊠嶪₼㠖䤓ⅉ❰⺖㲑㎞䍉㌷㙟∪ヺ┸ᇭ抨㢾₏檔⏜彊㦜╨ᇭ Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-753-8004. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d’interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d’assurance-médicaments. Pour accéder au service d’interprétation, il vous suffit de nous appeler au 1-800-753-8004. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: &K¼QJW¶LFµG୽FKY஗WK¶QJG୽FKPL୷QSK¯Ó୵WU୕OஏLF£FF¤XK஁LY୳FKŲţQJV஛FNK஁HY¢ FKŲţQJWU®QKWKXஃFPHQ1ୱXTX¯Y୽F୙QWK¶QJG୽FKYL¬Q[LQJ୿L 1-800-753-8004V୯FµQK¤QYL¬QQµL WLୱQJ9L୹WJL¼SÓஓTX¯Y୽Ò¤\O¢G୽FKY஗PL୷QSK¯ German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-753-8004. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 鲮ꩡ鱉넍ꊁꚩ뾍鿅鱉꼲븽ꚩ뾍꾅隵뼑덽ꓭ꾅鲪뼩麑ꍡ隕녅ꓩꊁ뭪꾢꫑ꟹ걙ꌱ 뇑險뼍隕넽걪鱽鲙뭪꾢꫑ꟹ걙ꌱ넩끞뼍ꇙꐩ놹쀉1-800-753-8004꘽냱ꈑꓭ넍뼩늱겢겑꿙 뼑霢꽩ꌱ뼍鱉鲩鲮녅閵鵹꿵麑ꍩ阸넺鱽鲙넩꫑ꟹ걙鱉ꓩꊁꈑ끩꾶鷞鱽鲙 Russian: ̬͒͘͏͚͉͇͉͕͎͔͘͏͔͚͙͉͕͖͕͕͙͔͕͑͗͘͘͢͏͙͔͕͙͇͕͉͕͕͌͒ͣ͗͊͘͜͏͒͏͓͌͋͏͇͓͔͙͔͕͕͖͇͔͇͑͌͊͒ ͉͓͕͍͙͉͕͖͕͎͕͉͇͙͔͇͌͌͒ͣͣͦ͘͘͢͟͏͓͏͈͖͇͙͔͓͌͒͘͢͏͚͚͇͓͒͊͘͏͖͉͕͌͗͌͋͞͏͕͉͙͕͈͑̾͢ ͉͕͖͕͎͕͉͇͙͚͚͇͓͒ͣͣͦ͒͊͘͘͘͏͖͉͕͌͗͌͋͞͏͇͖͕͎͉͕͔͑͏͙͔͇͓͖͕͙͕͔͚͌͌͒͌͛ 1-800-753-8004̩͇͓ ͕͇͍͙͖͕͓͕͕͙͚͔͑͌ͣ͗͋͘͠͏͕͙͕͕͉͕͑͑͗͐͊͗͢͏͙͖͕S͚͑͘͘͏̫͇͔͔͇͚͚͇͈͖͇͙͔͇ͦ͒͊͌͒ͦ͘͘

Arabic: 4008-357-008-1 Hindi: ֛֐֧֚֭֚֭֞֒֗֞և֑֑֭֞ֈ֗֞շ֑֠֫վ֊֞շ֧֎֧֞֒֐֧եը֌շ֧շ֚֟֠֏֠֌֭֭֒֘֊շ֧վ֗֞֎ֈ֧֊֧շ֧֔֟ձ֛֐֧֞֒֌֚֞֐֡֍֭ֆ ֈ֡֏֑֧֚֞֙֟֞֗֞ձդի֌֔֎֭։֛֨եձշֈ֡֏֑֞֙֟֞֌֭֒֞֌֭ֆշ֒֊֧շ֧֔֟ձ֎֛֚֐֧ե 1-800-753-8004֌֒֍֫֊շ֧֒եշ֫ժ֑֭֗շ֭ֆ֟ վ֛֫֟֊֭ֈ֠֎֫֔ֆ֛֞֨ը֌շ֠֐ֈֈշ֚֒շֆ֛֑֛֞֨ձշ֐֡֍֭ֆ֧֛֚֗֞֨ Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-800-753-8004. Un nostro incaricato che parla Italianovi fornirà l’assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-800-753-8004. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-800-753-8004. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-800-753-8004. Ta usługa jest bezpłatna. Japanese: ㇢䯍ቑ⋴ㅆ⋴ㅆ≬椉ቋ堻❐⑵㡈堻ኴ዆ዐ቎栱ሼቮሷ役⟞቎ር䷣ራሼቮቂቤ቎ᇬ䎰㠨ቑ 抩峂ኒዙኰኖሯሥቭቡሼሷሹሧቡሼᇭ抩峂ትሷ䞷✌቎ቍቮ቎ቒᇬ1-800-753-8004቎ር榊崀ሲቃሸ ሧᇭ㡴㦻崭ት崀ሼⅉ劔ሯ㞾㚃ሧቂሺቡሼᇭሶቯቒ䎰㠨ቑኒዙኰኖቊሼᇭ

PDOH17PD3863822_002